Thoracic imaging tests for the diagnosis of COVID-19

BACKGROUND

The respiratory illness caused by SARS-CoV-2 infection continues to present diagnostic challenges. Early research showed thoracic (chest) imaging to be sensitive but not specific in the diagnosis of coronavirus disease 2019 (COVID-19). However, this is a rapidly developing field and these findings need to be re-evaluated in the light of new research. This is the first update of this 'living systematic review'. This update focuses on people suspected of having COVID-19 and excludes studies with only confirmed COVID-19 participants.

OBJECTIVES

To evaluate the diagnostic accuracy of thoracic imaging (computed tomography (CT), X-ray and ultrasound) in people with suspected COVID-19.

SEARCH METHODS

We searched the COVID-19 Living Evidence Database from the University of Bern, the Cochrane COVID-19 Study Register, The Stephen B. Thacker CDC Library, and repositories of COVID-19 publications through to 22 June 2020. We did not apply any language restrictions.

SELECTION CRITERIA

We included studies of all designs that recruited participants of any age group suspected to have COVID-19, and which reported estimates of test accuracy, or provided data from which estimates could be computed. When studies used a variety of reference standards, we retained the classification of participants as COVID-19 positive or negative as used in the study.

DATA COLLECTION AND ANALYSIS

We screened studies, extracted data, and assessed the risk of bias and applicability concerns using the QUADAS-2 domain-list independently, in duplicate. We categorised included studies into three groups based on classification of index test results: studies that reported specific criteria for index test positivity (group 1); studies that did not report specific criteria, but had the test reader(s) explicitly classify the imaging test result as either COVID-19 positive or negative (group 2); and studies that reported an overview of index test findings, without explicitly classifying the imaging test as either COVID-19 positive or negative (group 3). We presented the results of estimated sensitivity and specificity using paired forest plots, and summarised in tables. We used a bivariate meta-analysis model where appropriate. We presented uncertainty of the accuracy estimates using 95% confidence intervals (CIs).

MAIN RESULTS

We included 34 studies: 30 were cross-sectional studies with 8491 participants suspected of COVID-19, of which 4575 (54%) had a final diagnosis of COVID-19; four were case-control studies with 848 cases and controls in total, of which 464 (55%) had a final diagnosis of COVID-19. Chest CT was evaluated in 31 studies (8014 participants, 4224 (53%) cases), chest X-ray in three studies (1243 participants, 784 (63%) cases), and ultrasound of the lungs in one study (100 participants, 31 (31%) cases). Twenty-six per cent (9/34) of all studies were available only as preprints. Nineteen studies were conducted in Asia, 10 in Europe, four in North America and one in Australia. Sixteen studies included only adults, 15 studies included both adults and children and one included only children. Two studies did not report the ages of participants. Twenty-four studies included inpatients, four studies included outpatients, while the remaining six studies were conducted in unclear settings. The majority of included studies had a high or unclear risk of bias with respect to participant selection, index test, reference standard, and participant flow. For chest CT in suspected COVID-19 participants (31 studies, 8014 participants, 4224 (53%) cases) the sensitivity ranged from 57.4% to 100%, and specificity ranged from 0% to 96.0%. The pooled sensitivity of chest CT in suspected COVID-19 participants was 89.9% (95% CI 85.7 to 92.9) and the pooled specificity was 61.1% (95% CI 42.3 to 77.1). Sensitivity analyses showed that when the studies from China were excluded, the studies from other countries demonstrated higher specificity compared to the overall included studies. When studies that did not classify index tests as positive or negative for COVID-19 (group 3) were excluded, the remaining studies (groups 1 and 2) demonstrated higher specificity compared to the overall included studies. Sensitivity analyses limited to cross-sectional studies, or studies where at least two reverse transcriptase polymerase chain reaction (RT-PCR) tests were conducted if the first was negative, did not substantively alter the accuracy estimates. We did not identify publication status as a source of heterogeneity. For chest X-ray in suspected COVID-19 participants (3 studies, 1243 participants, 784 (63%) cases) the sensitivity ranged from 56.9% to 89.0% and specificity from 11.1% to 88.9%. The sensitivity and specificity of ultrasound of the lungs in suspected COVID-19 participants (1 study, 100 participants, 31 (31%) cases) were 96.8% and 62.3%, respectively. We could not perform a meta-analysis for chest X-ray or ultrasound due to the limited number of included studies.

AUTHORS' CONCLUSIONS

Our findings indicate that chest CT is sensitive and moderately specific for the diagnosis of COVID-19 in suspected patients, meaning that CT may have limited capability in differentiating SARS-CoV-2 infection from other causes of respiratory illness. However, we are limited in our confidence in these results due to the poor study quality and the heterogeneity of included studies. Because of limited data, accuracy estimates of chest X-ray and ultrasound of the lungs for the diagnosis of suspected COVID-19 cases should be carefully interpreted. Future diagnostic accuracy studies should pre-define positive imaging findings, include direct comparisons of the various modalities of interest on the same participant population, and implement improved reporting practices. Planned updates of this review will aim to: increase precision around the accuracy estimates for chest CT (ideally with low risk of bias studies); obtain further data to inform accuracy of chest X-rays and ultrasound; and obtain data to further fulfil secondary objectives (e.g. 'threshold' effects, comparing accuracy estimates across different imaging modalities) to inform the utility of imaging along different diagnostic pathways.

Assessment of Health Conditions and Health Service Use Among Transgender Patients in Canada

IMPORTANCE

Transgender individuals experience stigma, discrimination, and socioeconomic disadvantages, leading to a myriad of poor health outcomes and high rates of disease burden; however, transgender health continues to be an understudied area.

OBJECTIVE

To examine sociodemographic characteristics, health conditions, and health service utilization patterns among transgender individuals compared with the general population.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of 2085 transgender individuals from 3 large cities in Ontario, Canada, compared characteristics and health service use among transgender individuals with the general population in the province. Transgender individuals were identified through data obtained from 4 outpatient community and hospital clinics, which were linked with health administrative data between January 2012 and December 2016. Data were analyzed between October 2018 and May 2020. Individuals were age-matched 1:5 to a random 5% sample of the general Ontario population (10 425 individuals).

MAIN OUTCOMES AND MEASURES

Sociodemographic variables, health service use, and chronic conditions among transgender individuals and the general population were compared.

RESULTS

This study included a sample of 2085 transgender individuals with a mean (SD) age of 30.40 (12.81) years; 771 (37.0%) identified as transgender women. Compared with 10 425 cisgender controls, trangender individuals were more likely to live in lower-income neighborhoods (lowest-income quintile: 625 [30.0%] vs 2197 [21.1%]; P < .001) and experience chronic physical and mental health conditions, including higher rates of asthma (489 [23.5%] vs 2034 [19.5%]; P < .001), diabetes (115 [5.5%] vs 352 [3.4%]; P < .001), chronic obstructive pulmonary disease (51 [2.4%] vs 156 [1.5%]; P < .001), and HIV (34 [1.6%] vs 12 [0.1%]; P < .001). Comorbid chronic health conditions were higher among the transgender population compared with the cisgender population (702 [33.7%] vs 2941 [28.2%]; P < .001). Transgender individuals also had higher health service use compared with the general population, particularly for mental health and self-harm, including mean (SD) number of psychiatrist visits between January 2012 and December 2016 (8.25 [23.13] vs 0.93 [9.57]; standardized difference, 5.84).

CONCLUSIONS AND RELEVANCE

This study found higher rates of mental and physical comorbidities and higher health service use among transgender individuals compared with cisgender individuals. Further research should explore reasons for these findings. Clinicians caring for transgender individuals should be aware of the high potential for mental health issues and self-harm.

Lipid Profile and Risk of Bone Fracture: A Systematic Review and Meta-Analysis of Observational Studies

Purpose: Earlier studies have linked lipid profile to osteoporotic fractures; however, to our knowledge, no study had summarized available data on this relationship. We aimed to summarize the current evidence on the association between lipid profile and bone fractures. Material and Methods: A systematic search of PubMed and Scopus was done to find relevant published studies until March 2018. To combine effect sizes, we applied fixed- or random-effects analysis, where appropriate. Cochran's Q test and I² were used to assess between-study heterogeneity. Results: Overall, 11 studies (seven prospective, three cross-sectional and one case-control studies) were included in the current systematic review. Out of them, 10 studies with a total sample size of 60,484 individuals, aged 25 years or more, were used in the meta-analysis. The results showed that total cholesterol concentration was positively associated with risk of bone fracture; such that a 50-mg/dl increase in plasma level of TC was associated with 15% greater odds of bone fracture (combined effect size: 1.15, 95% CI: 1.02-1.30, P = .02). Furthermore, we found that individuals with a decreased level of HDL (<40 mg/dl) had a lower risk of bone fracture compared with those with a normal level (≥40 mg/dl) (combined effect size: 0.82, 95% CI: 0.71-0.96, P = .01). No significant association was found between plasma level of TG and LDL with the risk of bone fractures either in prospective or cross-sectional studies. Conclusions: We found that plasma levels of total cholesterol were positively associated with bone fractures. In addition, decreased levels of HDL were associated with an increased risk of osteoporotic fractures. Abbreviations: TG: triglycerides, TC: total cholesterol, HDL: high-density lipoprotein, LDL: low-density lipoprotein, OR: odds ratio, RR: relative risk, HR: hazard ratio, DXA: dual-energy X-ray absorptiometry, ICD: International Classification of Diseases, SD: standard deviation.

Impact of social support on oral health among immigrants and ethnic minorities: A systematic review

Objective

Adaptation to social life changes after migration may be beneficial or detrimental to migrants’ oral health outcomes and related behaviors. This systematic review aims to synthesize the scientific literature on the impact of social support on immigrants’ and ethnic minorities’ oral health status and/or behaviors.

Methods

A comprehensive electronic search, up to November 2018, was conducted using five electronic databases. We included cross-sectional and longitudinal quantitative studies that examine associations between social support and oral health outcomes among immigrants and ethnic minorities. Study selection, data extraction, and risk of bias assessment were completed in duplicate and the Newcastle-Ottawa checklist was used to appraise the methodological quality of the quantitative studies.

Results

A total of 26 studies met the eligibility criteria. Included studies examined multiple oral health outcomes such as dental care utilization, oral health behaviors, oral health problems, self-rated oral health, oral health knowledge, and oral health-related quality of life among immigrants and ethnic minorities. The social support level is assessed either by social support indicators or by adapting certain scales. Overall, social support was found to be positively associated with dental care utilization, number of carious teeth, periodontal disease, oral health behaviors, oral health knowledge, oral health-related quality of life, and self-rated oral health.

Conclusion

Although immigrants and ethnic minorities encounter several challenges after migration to a new country that could affect their oral health, social support from their surrounding environment in the form of structural or functional support plays an important role in improving their oral health outcomes.

Insights on Allergic Rhinitis Management from a Northern Cyprus Perspective and Evaluation of the Impact of Pharmacist-Led Educational Intervention on Patients' Outcomes

BACKGROUND AND OBJECTIVE

the global prevalence of allergic rhinitis (AR) is rising and yet there is scarce information concerning the diagnosis, management and treatment patterns of AR in Northern Cyprus (NC). This study aims to provide a unique perspective on AR management as well as assessing the effectiveness of the pharmacist-led educational intervention for improving care of AR patients.

METHODS

across-sectional survey was carried out with community pharmacists (n = 70), patients (n = 138) and ear, nose and throat (ENT) specialists (n = 12) in NC. For a controlled interventional trial, trained pharmacists provided a brief education on management of AR and nasal spray technique for patients while other pharmacists provided the usual care. Quality of life (QoL) and other outcome measures on the perceived symptom severity of the two groups were compared after a 6-week period.

RESULTS

only 33.3% of the ear, nose and throat (ENT) specialists and 15.7% of the community pharmacists are aware of the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines. The majority of patients (63%) self-managed with over-the-counter medications. Nasal congestion (96.4%) is the most bothersome symptom and oral antihistamines are the most commonly purchased medications (51.4%), indicating a pattern of suboptimal management. The pharmacists-led educational intervention has resulted in statistically more significant improvement in regards to nasal congestion and QoL for the intervention group patients (p < 0.05).

CONCLUSION

the current management of AR has not been in accordance with the ARIA guidelines in NC. An educational intervention of the pharmacists can enhance the symptom management and improve the QoL in patients with AR.

Epidemiological Trend of Typhoid and Paratyphoid Fevers in Zhejiang Province, China from 1953 to 2014

Background: The incidences of typhoid and paratyphoid remain high and these diseases still pose a public health problem in China and in Zhejiang Province in particular. This study aimed to investigate the trend of typhoid and paratyphoid in Zhejiang Province from 1953 to 2014 and to provide a theoretical basis for the prevention and control of these diseases. Methods: Included in this study were compiled epidemiological data of typhoid and paratyphoid cases in Zhejiang from 1953 to 2003 and epidemiological data of those from 2004 to 2014 registered in the China Information System for Diseases Control and Prevention. Description methods were employed to explore the epidemiological characteristics, including long-term trend, gender distribution, age distribution, and occupation distribution. Incidence maps were made to represent the annual average incidences for each municipality. Spearman’s rank correlation was performed to detect the correlation between incidence and average elevation, and circular distribution was calculated to identify the seasonality and peak days of the diseases. A p-value of <0.05 was considered statistically significant. Results: A total of 182,602 typhoid and paratyphoid cases were reported in Zhejiang Province from 1953 to 2014, and the average annual incidence was 7.89 per 100,000 population. The incidence in 2014 decreased by 93.82% compared with that in 1953 and by 95.00% compared with the highest incidence rate. The average incidence before 2003 was negatively correlated with the average elevation of each region in Zhejiang province (r < 0, p < 0.05), but there was no statistically significant correlation from 2003. The peak period of diseases fell in the months from April to October every year. The incidence among the population group aged over 35 rose gradually but declined sharply among those between 20 and 34. Conclusions: The incidence of typhoid and paratyphoid decreased in Zhejiang Province from 1953 to 2014 but remained high in some regions. Proper measures for prevention and control are warranted in the southeast coast areas and for high-risk populations.

The association of smoking and risk of diabetic retinopathy in patients with type 1 and type 2 diabetes: a meta-analysis

PURPOSE

To clarify the relevance between smoking and diabetic retinopathy in patients with type 1 and type 2 diabetes mellitus.

METHODS

Published evidence were searched in MEDLINE and EMBASE from the databases began until Feb. 2017. Studies evaluating the association between smoking and diabetic retinopathy or evaluating the risk factors of diabetic retinopathy including smoking were included.

RESULTS

Totally 73 studies were identified, among which 19 studies included type 1 diabetes patients and 56 studies included type 2 diabetes patients. In type 1 diabetes, compare with non-smokers, the risk of diabetic retinopathy significantly increased in smokers (risk ratio (RR) = 1.23, 95% CI 1.14, 1.33, P < 0.001), and the risk of proliferative diabetic retinopathy also significantly increased in smokers (RR = 1.48, 95% CI 1.20, 1.81, P < 0.001). In type 2 diabetes, compare with non-smokers, the risk of diabetic retinopathy significantly decreased in smokers (RR = 0.92, 95% CI 0.86, 0.98, P = 0.02) and the risk of proliferative diabetic retinopathy also significantly decreased in smokers (RR = 0.68, 95% CI 0.61, 0.74, P < 0.001).

CONCLUSIONS

Compare with non-smokers, the risk of diabetic retinopathy significantly increased in smokers with type 1 diabetes while significantly decreased in smokers with type 2 diabetes. However, this result did not change the importance of smoking cessation for public health.

Bibliometrics of Tunisian publications in preventive and community medicine, indexed in the Medline database (1975-2014)

INTRODUCTION

With the aim of rebuilding the memory of the specialty of Preventive Medicine and Community Medicine (MPC) in Tunisia, through its indexed scientific publications, the objective of this work was to describe the thematic and methodological profile of indexed scientific research, of this specialty over four decades.

METHODS

This is a descriptive bibliometric study of MPC articles, indexed in the Medline database over a 40-year period (1975-2014), and based on their Medline Material Safety Data Sheets (MSDS). All articles of which the first and / or last authors were MPC university hospital teachers, in one of Tunisia's four faculties of medicine, were included. The themes of the publications were defined through the major keywords (Majr), and categorized according to the following five groups: "non-communicable diseases", "communicable diseases", "violence and traumatisms", "management of health services" and "Research and pedagogy".

RESULTS

Among 1664 articles captured by the Medline-based documentary request, 594 had as their first authors, teachers of the MPC specialty and 365 articles were eligible for study. The productivity of the specialty of MPC increased from 29 publications between 1975 and 1984, to 167 between 2005 and 2014. The magazine "La Tunisie Médicale" published 37.6% of the articles of this specialty. Four out of ten MPC papers referred to hospital structures and 35% of them were cross-sectional observational studies. Over the decades, an increase in research topics related to "non-communicable diseases" versus "communicable diseases" has been noted in MPC.

CONCLUSION

In Tunisia, research in MPC has been relatively prolific and globally consistent with the health needs of the population (impacted by the epidemiological transition). The orientation of research projects towards community-based proposals, of high methodological level and mobilizing multidisciplinary teams, would be necessary for the improvement of the quality and relevance of publications in MPC.

Clinical trial transparency: a reassessment of industry compliance with clinical trial registration and reporting requirements in the United States

OBJECTIVE

To evaluate the accuracy of a 2015 cross-sectional analysis published in the BMJ Open which reported that pharmaceutical industry compliance with clinical trial registration and results reporting requirements under US law was suboptimal and varied widely among companies.

DESIGN

We performed a reassessment of the data reported in Miller et al to evaluate whether statutory compliance analyses and conclusions were valid.

DATA SOURCES

Information from the Dryad Digital Repository, ClinicalTrials.gov, Drugs@FDA and direct communications with sponsors.

MAIN OUTCOME MEASURES

Compliance with the clinical trial registration and results reporting requirements under the Food and Drug Administration Amendments Act (FDAAA).

RESULTS

Industry compliance with FDAAA disclosure requirements was notably higher than reported by Miller et al. Among trials subject to FDAAA, Miller et al reported that, per drug, a median of 67% (middle 50% range: 0%-100%) of trials fully complied with registration and results reporting requirements. On reanalysis of the data, we found that a median of 100% (middle 50% range: 93%-100%) of clinical trials for a particular drug fully complied with the law. When looking at overall compliance at the trial level, our reassessment yields 94% timely registration and 90% timely results reporting among the 49 eligible trials, and an overall FDAAA compliance rate of 86%.

CONCLUSIONS

The claim by Miller et al that industry compliance is below legal standards is based on an analysis that relies on an incomplete dataset and an interpretation of FDAAA that requires disclosure of study results for drugs that have not yet been approved for any indication. On reanalysis using a different interpretation of FDAAA that focuses on whether results were disclosed within 30 days of drug approval, we found that industry compliance with US statutory disclosure requirements for the 15 reviewed drugs was consistently high.

Determinants associated with deprivation in multimorbid patients in primary care-A cross-sectional study in Switzerland

BACKGROUND

Deprivation usually encompasses material, social, and health components. It has been shown to be associated with greater risks of developing chronic health conditions and of worse outcome in multimorbidity. The DipCare questionnaire, an instrument developed and validated in Switzerland for use in primary care, identifies patients subject to potentially higher levels of deprivation.

OBJECTIVES

To identifying determinants of the material, social, and health profiles associated with deprivation in a sample of multimorbid, primary care patients, and thus set priorities in screening for deprivation in this population.

DESIGN

Secondary analysis from a nationwide cross-sectional study in Switzerland.

PARTICIPANTS

A random sample of 886 adult patients suffering from at least three chronic health conditions.

MAIN MEASURES

The outcomes of interest were the patients' levels of deprivation as measured using the DipCare questionnaire. Classification And Regression Tree analysis identified the independent variables that separated the examined population into groups with increasing deprivation scores. Finally, a sensitivity analysis (multivariate regression) confirmed the robustness of our results.

KEY RESULTS

Being aged under 64 years old was associated with higher overall, material, and health deprivation; being aged over 77 years old was associated with higher social deprivation. Other variables associated with deprivation were the level of education, marital status, and the presence of depression or chronic pain.

CONCLUSION

Specific profiles, such as being younger, were associated with higher levels of overall, material, and health deprivation in multimorbid patients. In contrast, patients over 77 years old reported higher levels of social deprivation. Furthermore, chronic pain and depression added to the score for health deprivation. It is important that GPs consider the possibility of deprivation in these multimorbid patients and are able to identify it, both in order to encourage treatment adherence and limit any forgoing of care for financial reasons.

VI. PERSON-SPECIFIC INDIVIDUAL DIFFERENCE APPROACHES IN DEVELOPMENTAL RESEARCH

In this chapter, we demonstrate the way certain common analytic approaches (e.g., polynomial curve modeling, repeated measures ANOVA, latent curve, and other factor models) create individual difference measures based on a common underlying model. After showing that these approaches require only means and covariance (or correlation) matrices to estimate regression coefficients based on a hypothesized model, we describe how to recast these models based on time-series related approaches focusing on single subject time series approaches (e.g., vector autoregressive approaches and P-technique factor models). We show how these latter methods create parameters based on models that can vary from individual-to-individual. We demonstrate differences for the factor model using real data examples.

Myopia and diabetic retinopathy: A systematic review and meta-analysis

AIMS

Myopia may have protective effects against diabetic retinopathy (DR). However, the data from epidemiologic studies are inconsistent. We aimed to examine the association between myopia and DR by conducting a meta-analysis.

METHODS

We identified studies by searching the PubMed and EMBASE databases. Study-specific odds ratios (ORs) were pooled using a fixed or random effects model. Myopic eyes were defined as having a spherical equivalent (SE)<-0.5 diopters (D). Myopic SE, each diopter decrease in SE toward myopia, and each millimeter increase in axial length (AL) were used as independent surrogate variables for myopia.

RESULTS

Data from 6 population-based and 3 clinic-based studies were included in the analyses. Myopic SE (compared with emmetropic eyes) and each millimeter increase in AL were associated with a decreased risk for DR (pooled odds ratio [OR], 0.80 and 0.79, respectively; 95% confidence interval [CI], 0.67-0.95 and 0.73-0.86, respectively; P=0.011 and 0.000, respectively). Each millimeter increase in AL was also associated with a decreased risk for vision-threatening diabetic retinopathy (VTDR) (pooled OR, 0.70; 95% CI, 0.60-0.82; P=0.000). No significant association between each diopter decrease in SE and DR was observed.

CONCLUSIONS

Our meta-analysis suggests that individuals with myopia exhibit a decreased risk of developing DR or VTDR. An increased AL plays a critical role in this protective effect.

Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis

IMPORTANCE

Physicians in training are at high risk for depression. However, the estimated prevalence of this disorder varies substantially between studies.

OBJECTIVE

To provide a summary estimate of depression or depressive symptom prevalence among resident physicians.

DATA SOURCES AND STUDY SELECTION

Systematic search of EMBASE, ERIC, MEDLINE, and PsycINFO for studies with information on the prevalence of depression or depressive symptoms among resident physicians published between January 1963 and September 2015. Studies were eligible for inclusion if they were published in the peer-reviewed literature and used a validated method to assess for depression or depressive symptoms.

DATA EXTRACTION AND SYNTHESIS

Information on study characteristics and depression or depressive symptom prevalence was extracted independently by 2 trained investigators. Estimates were pooled using random-effects meta-analysis. Differences by study-level characteristics were estimated using meta-regression.

MAIN OUTCOMES AND MEASURES

Point or period prevalence of depression or depressive symptoms as assessed by structured interview or validated questionnaire.

RESULTS

Data were extracted from 31 cross-sectional studies (9447 individuals) and 23 longitudinal studies (8113 individuals). Three studies used clinical interviews and 51 used self-report instruments. The overall pooled prevalence of depression or depressive symptoms was 28.8% (4969/17,560 individuals, 95% CI, 25.3%-32.5%), with high between-study heterogeneity (Q = 1247, τ2 = 0.39, I2 = 95.8%, P < .001). Prevalence estimates ranged from 20.9% for the 9-item Patient Health Questionnaire with a cutoff of 10 or more (741/3577 individuals, 95% CI, 17.5%-24.7%, Q = 14.4, τ2 = 0.04, I2 = 79.2%) to 43.2% for the 2-item PRIME-MD (1349/2891 individuals, 95% CI, 37.6%-49.0%, Q = 45.6, τ2 = 0.09, I2 = 84.6%). There was an increased prevalence with increasing calendar year (slope = 0.5% increase per year, adjusted for assessment modality; 95% CI, 0.03%-0.9%, P = .04). In a secondary analysis of 7 longitudinal studies, the median absolute increase in depressive symptoms with the onset of residency training was 15.8% (range, 0.3%-26.3%; relative risk, 4.5). No statistically significant differences were observed between cross-sectional vs longitudinal studies, studies of only interns vs only upper-level residents, or studies of nonsurgical vs both nonsurgical and surgical residents.

CONCLUSIONS AND RELEVANCE

In this systematic review, the summary estimate of the prevalence of depression or depressive symptoms among resident physicians was 28.8%, ranging from 20.9% to 43.2% depending on the instrument used, and increased with calendar year. Further research is needed to identify effective strategies for preventing and treating depression among physicians in training.

Cognition and the risk of eating disorders in Spanish adolescents: the AVENA and AFINOS studies

Eating disorders (ED) can arise from a combination of biological and psychological factors. Some studies suggest that intellectual factors might be important in the development of ED, although the evidence is still scarce. The aim of this study was to examine the association between cognition measurements (cognitive performance and academic achievement) and the risk of developing ED in adolescents considering their weight status. The sample consisted of 3,307 adolescents (1,756 girls), aged 13-18.5 years, who participated in the AVENA (n = 1,430; 783 girls) and AFINOS (n = 1,877; 973 girls) studies. Cognitive performance was measured by the TEA test in the AVENA study, and academic achievement was self-reported in the AFINOS study. ED risk was evaluated in both studies by using the SCOFF questionnaire. Body mass index was calculated to classify adolescents as non-overweight or overweight (including obesity). Overweight adolescents showed a higher risk of developing ED than non-overweight ones in both studies. In the AVENA study, overweight boys with low performance in reasoning ability showed increased risk of ED (p = 0.05). In the AFINOS study, overweight boys with low academic performance in physical education and non-overweight girls with low academic achievement in all the areas analyzed showed higher risk of ED than their peers (all p < 0.05).

CONCLUSION

No association between cognitive performance and ED risk was found in adolescents, while academic achievement was associated with ED risk, especially in non-overweight girls. The non-cognitive traits that accompany academic achievement could influence the likelihood of developing ED in these girls.

Thyroglobulin in lymph node fine-needle aspiration washout: a systematic review and meta-analysis of diagnostic accuracy

CONTEXT

The thyroglobulin measurement in the needle washout after fine-needle aspiration (FNA) has been reported to increase the sensitivity of FNA in identifying lymph node (LN) metastases from differentiated thyroid cancer (DTC).

OBJECTIVE

The aim of the study was to estimate the diagnostic accuracy of this technique.

DATA SOURCES

To identify eligible studies, we searched electronic databases for original articles in English from 1975 through 2013.

STUDY SELECTION

Studies that enrolled participants with suspicious neck LNs during thyroid nodule workup or thyroid cancer follow-up were included.

DATA EXTRACTION

Working independently, authors used a standard form to extract data. For quality assessment, QUADAS2 guidelines were applied.

DATA SYNTHESIS

Including all the selected studies (24 studies, 2865 LNs) in the pooled analysis, overall sensitivity was 95.0% (95% confidence interval [CI], 93.7-96.0%), specificity was 94.5% (95% CI, 93.2-95.7%), and diagnostic odds ratio (DOR) was 338.91 (95% CI, 164.82-696.88) with significant heterogeneity (inconsistency [I(2)] = 65.7%; heterogeneity, P < .001). Stratifying different populations and including only patients with thyroid gland (410 LNs), pooled sensitivity was 86.2% (95% CI, 80.9-90.5%), specificity was 90.2% (85.1-94.0%), and DOR was 56.621 (22.535-142.26; I(2) = 37.3%; heterogeneity, P = .121). Including only patients after thyroidectomy (1007 LNs), pooled sensitivity was 96.9% (95% CI, 94.9-98.2%), specificity was 94.1% (91.7-96.0%), and DOR was 407.65 (198.67-836.46; I(2) = 0.0%; heterogeneity, P = .673).

CONCLUSIONS

Thyroglobulin measurement in washout from LN FNA has high accuracy in early detection of nodal metastases from DTC. The technique is simple, but a better standardization of criteria for patient selection, analytical methods, and cutoff levels is required.

Awareness of climate change and the dietary choices of young adults in Finland: a population-based cross-sectional study

Climate change is a major public health threat that is exacerbated by food production. Food items differ substantially in the amount of greenhouse gases their production generates and therefore individuals, if willing, can mitigate climate change through dietary choices. We conducted a population-based cross-sectional study to assess if the understanding of climate change, concern over climate change or socio-economic characteristics are reflected in the frequencies of climate-friendly food choices. The study population comprised 1623 young adults in Finland who returned a self-administered questionnaire (response rate 64.0%). We constructed a Climate-Friendly Diet Score (CFDS) ranging theoretically from −14 to 14 based on the consumption of 14 food items. A higher CFDS indicated a climate-friendlier diet. Multivariate linear regression analyses on the determinants of CFDS revealed that medium concern raised CFDS on average by 0.51 points (95% confidence interval (CI) 0.03, 0.98) and high concern by 1.30 points (95% CI 0.80, 1.80) compared to low concern. Understanding had no effect on CFDS on its own. Female gender raised CFDS by 1.92 (95% CI 1.59, 2.25). Unemployment decreased CFDS by 0.92 (95% CI −1.68, −0.15). Separate analyses of genders revealed that high concern over climate change brought about a greater increase in CFDS in females than in males. Good understanding of climate change was weakly connected to climate-friendly diet among females only. Our results indicate that increasing awareness of climate change could lead to increased consumption of climate-friendly food, reduction in GHG emissions, and thus climate change mitigation.

Blood vitamin D status and metabolic syndrome in the general adult population: a dose-response meta-analysis

CONTEXT

Increasing evidence has suggested an association between blood vitamin D levels and metabolic syndrome.

OBJECTIVE

Our objective was to determine the relationship between blood vitamin D status and metabolic syndrome in the general adult population, using a dose-response meta-analysis.

DATA SOURCE

We searched the PubMed, EMBASE, Web of Science, and Cochrane Library databases through July 2013 to identify relevant studies.

STUDY SELECTION

Observational studies, reporting risk ratios with a 95% confidence interval (CI) for metabolic syndrome in ≥3 categories of blood 25-hydroxyvitamin D [25(OH)D] levels, were selected.

DATA EXTRACTION

Data extraction was performed independently by 2 authors, and the quality of the studies was evaluated using the risk of bias assessment tool for nonrandomized studies.

DATA SYNTHESIS

The pooled odds ratio of metabolic syndrome per 25 nmol/L increment in the serum/plasma 25(OH)D concentration was 0.87 (95% CI = 0.83-0.92, I(2) = 85%), based on 16 "cross-sectional studies" and 1.00 (95% CI = 0.98-1.02, I(2) = 0%) for 2 "cohort and nested case-control studies." The dose-response meta-analysis showed a generally linear, inverse relationship between 25(OH)D levels and metabolic syndrome in the cross-sectional studies (P for linear trend < .001).

CONCLUSIONS

Blood vitamin D levels were associated with a risk of metabolic syndrome in cross-sectional studies but not in longitudinal studies. Randomized, clinical trials will be necessary to address the issue of causality and to determine whether vitamin D supplementation is effective for the prevention of metabolic syndrome.

[Occupational diseases in Poland, 2012]

BACKGROUND

The aim of the paper was to present basic statistical data on occupational diseases diagnosed in 2012.

MATERIAL AND METHODS

The work was based on the data from "Occupational Disease Reporting Forms" received by the Central Register of Occupational Diseases in 2012. The data comprised information on nosologic units, gender and age of patients, duration of occupational exposure, sections of the national economy and voivodeships. The incidence was specified in terms of the number of cases in relation to paid employees or to employed people.

RESULTS

The number of occupational diseases accounted for 2402 cases. The incidence rate was 23 cases per 100 000 paid employees. In spite of the general decline in the number of cases, the incidence of infectious and parasitic diseases increased by 8.6%. The highest incidence was noted for infectious and parasitic diseases (6.8/100,000), pneumoconioses (5.5/100,000), hearing loss (2.1/100,000), diseases of: the peripheral nervous system (2/100,000), voice disorders (1.9/100,000) and the musculoskeletal system pathologies (1.1/100,000). The pathologies specified above accounted in total for 84% of all occupational diseases. The industrial sectors of the national economy characterized by the highest incidence included mining and quarrying (288.3/100,000) and manufacturing (27.8/100,000). The highest incidence was recorded in the Silesian (46.2/100,000) and the lowest in the Opolskie (4.2/100,000) voivodeships.

CONCLUSIONS

The downward trend in the incidence of occupational diseases continues. Different incidence of voice disorders among teachers in individual provinces suggests that uniform preventive, diagnostic and certification standards are missing.

Value of audio-enhanced handheld computers over paper surveys with adolescents

OBJECTIVE

To examine the impact of 3 data collection modes on the number of questions answered, data quality, and student preference.

METHODS

275 urban seventh-grade students were recruited and randomly assigned to complete a paper survey (SAQ), PDA survey (PDA), or PDA survey with audio (APDA). Students completed a paper debriefing survey.

RESULTS

APDA respondents completed significantly more questions compared to SAQ and PDA. PDA and APDA had significantly less missing data than did SAQ. No differences were found for student evaluation.

CONCLUSIONS

Strong benefits may be gained by the use of APDA for adolescent school-based data collection.

Socioeconomic status and health communication inequalities in Japan: a nationwide cross-sectional survey

Background

Considerable evidence suggests that communication inequality is one potential mechanism linking social determinants, particularly socioeconomic status, and health inequalities. This study aimed to examine how dimensions of health communication outcomes (health information seeking, self-efficacy, exposure, and trust) are patterned by socioeconomic status in Japan.

Methods

Data of a nationally representative cross-sectional survey of 2,455 people aged 15–75 years in Japan were used for secondary analysis. Measures included socio-demographic characteristics, subjective health, recent health information seeking, self-efficacy in seeking health information, and exposure to and trust in health information from different media.

Results

A total of 1,311 participants completed the questionnaire, giving a response rate of 53.6%. Multivariate logistic regression revealed that education and household income, but not employment, were significantly associated with health information seeking and self-efficacy. Socioeconomic status was not associated with exposure to and trust in health information from mass media, but was significantly associated with health information from healthcare providers and the Internet.

Conclusion

Health communication outcomes were patterned by socioeconomic status in Japan thus demonstrating the prevalence of health communication inequalities. Providing customized exposure to and enhancing the quality of health information by considering social determinants may contribute to addressing social disparities in health in Japan.

Unintended consequences of cigarette price changes for alcohol drinking behaviors across age groups: evidence from pooled cross sections

BACKGROUND

Raising prices through taxation on tobacco and alcohol products is a common strategy to raise revenues and reduce consumption. However, taxation policies are product specific, focusing either on alcohol or tobacco products. Several studies document interactions between the price of cigarettes and general alcohol use and it is important to know whether increased cigarette prices are associated with varying alcohol drinking patterns among different population groups. To inform policymaking, this study investigates the association of state cigarette prices with smoking, and current, binge, and heavy drinking by age group.

METHODS

The 2001-2006 Behavioral Risk Factor Surveillance System surveys (n = 1,323,758) were pooled and analyzed using multiple regression equations to estimate changes in smoking and drinking pattern response to an increase in cigarette price, among adults aged 18 and older. For each outcome, a multiple linear probability model was estimated which incorporated terms interacting state cigarette price with age group. State and year fixed effects were included to control for potential unobserved state-level characteristics that might influence smoking and drinking.

RESULTS

Increases in state cigarette prices were associated with increases in current drinking among persons aged 65 and older, and binge and heavy drinking among persons aged 21-29. Reductions in smoking were found among persons aged 30-64, drinking among those aged 18-20, and binge drinking among those aged 65 and older.

CONCLUSIONS

Increases in state cigarette prices may increase or decrease smoking and harmful drinking behaviors differentially by age. Adults aged 21-29 and 65 and older are more prone to increased drinking as a result of increased cigarette prices. Researchers, practitioners, advocates, and policymakers should work together to understand and prepare for these unintended consequences of tobacco taxation policy.

Prevalence of and factors associated with daily smoking among Inner Mongolia medical students in China: a cross-sectional questionnaire survey

BACKGROUND

To date, no study on smoking behavior of medical students in Inner Mongolia has been reported. The aim of the present study was to determine the 1-month prevalence of and factors associated with daily smoking among medical students in Inner Mongolia of China, to assist interventions designed to reduce the smoking behavior of medical college students in this region.

METHODS

During December 2010 and January 2011 a cross-sectional survey was conducted among medical students at the Inner Mongolia Medical College using a self-administered questionnaire. The questionnaire consisted of three sections: students' basic information, attitude on smoking behavior, and smoking status of the student daily smokers. Students who smoked every day in the last 30 days were regarded as daily smokers. Factors associated with smoking were identified using binary logistic regression analysis.

RESULTS

A total of 6044 valid surveys were returned. The overall prevalence of daily smoking was 9.8% while the prevalence of daily smoking among males and females were 29.4% and 1.7%, respectively. Males in the Faculty of Medicine Information Management had the highest daily smoking rate (48.9%). Logistic regression models found that the main factors associated with daily smoking among male medical students were highest year of study (OR = 3.62; CI: 1.18-11.05); attitude towards smoking behavior Do not care about people smoking around you (OR = 2.75; CI: 2.08-3.64); and Smoking is harmful to their health (OR = 4.40; CI: 2.21-8.75). The main factor associated with daily smoking among female medical students was attitude towards smoking behavior Eliminate smoking on campus (OR = 0.11; CI: 0.06-0.23). Both for male and female medical students, there was no association between ethnicity and cigarette daily smoking. In regard to smoking status, more than 60% of daily smokers began smoking in high school, 61.3% smoked less than 5 cigarettes per day, 62.9% of the daily smokers' families opposed their smoking behavior, and after an hour of not smoking 74.6% daily smokers did not feel uncomfortable.

CONCLUSIONS

Antismoking education should be further promoted in Inner Mongolia medical students, with consideration given to the factors associated with daily smoking behavior found in the present study.

From the trenches: a cross-sectional study applying the GRADE tool in systematic reviews of healthcare interventions

Background

GRADE was developed to address shortcomings of tools to rate the quality of a body of evidence. While much has been published about GRADE, there are few empirical and systematic evaluations.

Objective

To assess GRADE for systematic reviews (SRs) in terms of inter-rater agreement and identify areas of uncertainty.

Design

Cross-sectional, descriptive study.

Methods

We applied GRADE to three SRs (n = 48, 66, and 75 studies, respectively) with 29 comparisons and 12 outcomes overall. Two reviewers graded evidence independently for outcomes deemed clinically important a priori. Inter-rater reliability was assessed using kappas for four main domains (risk of bias, consistency, directness, and precision) and overall quality of evidence.

Results

For the first review, reliability was: κ = 0.41 for risk of bias; 0.84 consistency; 0.18 precision; and 0.44 overall quality. Kappa could not be calculated for directness as one rater assessed all items as direct; assessors agreed in 41% of cases. For the second review reliability was: 0.37 consistency and 0.19 precision. Kappa could not be assessed for other items; assessors agreed in 33% of cases for risk of bias; 100% directness; and 58% overall quality. For the third review, reliability was: 0.06 risk of bias; 0.79 consistency; 0.21 precision; and 0.18 overall quality. Assessors agreed in 100% of cases for directness. Precision created the most uncertainty due to difficulties in identifying “optimal” information size and “clinical decision threshold”, as well as making assessments when there was no meta-analysis. The risk of bias domain created uncertainty, particularly for nonrandomized studies.

Conclusions

As researchers with varied levels of training and experience use GRADE, there is risk for variability in interpretation and application. This study shows variable agreement across the GRADE domains, reflecting areas where further guidance is required.

Goal-striving stress and the mental health of college-educated Black American men: the protective effects of system-blame

The present study examined the relationship between goal-striving stress and well-being in a survey of 399 college-educated Black American men who were members of a Black fraternal organization. Regression analyses revealed that goal-striving stress was associated with decreased psychological well-being, controlling for demographics and various psychosocial factors. When asked to explain their failure to reach life goals, half of the men attributed setbacks to racial discrimination. The association of goal-striving stress with diminished well-being was stronger among those who did not attribute setbacks to race than among those who did. These findings suggest that even with material success, Black men face blocked opportunities that could be consequential to their well-being.

A descriptive survey of types, spread and characteristics of substance abuse treatment centers in Nigeria

BACKGROUND

Nigeria, the most populous country in Africa and the 8th most populous in the world with a population of over 154 million, does not have current data on substance abuse treatment demand and treatment facilities; however, the country has the highest one-year prevalence rate of Cannabis use (14.3%) in Africa and ranks third in Africa with respect to the one-year prevalence rate of cocaine (0.7%) and Opioids (0.7%) use. This study aimed to determine the types, spread and characteristics of the substance abuse treatment centers in Nigeria.

METHODS

The study was a cross sectional survey of substance abuse treatment centers in Nigeria. Thirty-one units were invited and participated in filling an online questionnaire, adapted from the European Treatment Unit/Program Form (June 1997 version).

RESULTS

All the units completed the online questionnaire. A large proportion (48%) was located in the South-West geopolitical zone of the country. Most (58%) were run by Non-Governmental Organizations. Half of them performed internal or external evaluation of treatment process or outcome. There were a total of 1043 for all categories of paid and volunteer staff, with an average of 33 staff per unit. Most of the funding came from charitable donations (30%). No unit provided drug substitution/maintenance therapy. The units had a total residential capacity of 566 beds. New client admissions in the past one year totalled 765 (mean = 48, median = 26.5, min = 0, max = 147) and 2478 clients received services in the non-residential units in the past year. No unit provided syringe exchange services.

CONCLUSIONS

The study revealed a dearth of substance abuse treatment units (and of funds for the available ones) in a country with a large population size and one of the highest prevalence rates of substance abuse in Africa. The available units were not networked and lacked a directory or an evaluation framework. To provide an environment for effective monitoring, funding and continuous quality improvement, the units need to be organized into a sustainable network.

Depression and health related quality of life among HIV-infected people

BACKGROUND AND OBJECTIVES

Little is known about the impact of comorbid psychiatric symptoms in health related quality of life (HRQL) in patients with HIV infection. The aim of this investigation was to describe depressive symptoms and the impact in HRQL in HIV infected people.

MATERIALS AND METHODS

A cross-sectional study over 150 HIV-outpatients in a tertiary hospital was designed. Depression data were obtained using the Beck Depression Inventory, Second Edition (BDI-II) inventory. HRQL data were collected by disease-specific questionnaire MOS-HIV. Researchers' team designed a specific template to get rest of the data.

RESULTS

Almost three-quarters of the population were men. After adjusting for gender and age, HIV-related symptoms and presence of depression were found to be negatively associated with all the Medical Outcomes Study HIV Health Survey (MOS-HIV) general domains and in the Physical Health Summary score and Mental Health Summary score.

CONCLUSIONS

Optimization of HRQL is particularly important now that HIV is a chronic disease with the prospect of long-term survival. Quality of life and depression should be monitored in follow-up of HIV infected patients. Comorbid psychiatric conditions may serve as markers for impaired functioning and well-being in persons with HIV.

Comparing injection and non-injection routes of administration for heroin, methamphetamine, and cocaine users in the United States

Research examining the demographic and substance use characteristics of illicit drug use in the United States has typically failed to consider differences in routes of administration or has exclusively focused on a single route of administration?injection drug use. Data from National Survey on Drug Use and Health were used to compare past-year injection drug users and non-injection drug users' routes of administration of those who use the three drugs most commonly injected in the United States: heroin, methamphetamine, and cocaine. Injection drug users were more likely than those using drugs via other routes to be older (aged 35 and older), unemployed, possess less than a high school education, and reside in rural areas. IDUs also exhibited higher rates of abuse/dependence, perceived need for substance abuse treatment, and co-occurring physical and psychological problems. Fewer differences between IDUs and non-IDUs were observed for heroin users compared with methamphetamine or cocaine users.

Comparing injection and non-injection routes of administration for heroin, methamphetamine, and cocaine users in the United States

Research examining the demographic and substance use characteristics of illicit drug use in the United States has typically failed to consider differences in routes of administration or has exclusively focused on a single route of administration?injection drug use. Data from National Survey on Drug Use and Health were used to compare past-year injection drug users and non-injection drug users' routes of administration of those who use the three drugs most commonly injected in the United States: heroin, methamphetamine, and cocaine. Injection drug users were more likely than those using drugs via other routes to be older (aged 35 and older), unemployed, possess less than a high school education, and reside in rural areas. IDUs also exhibited higher rates of abuse/dependence, perceived need for substance abuse treatment, and co-occurring physical and psychological problems. Fewer differences between IDUs and non-IDUs were observed for heroin users compared with methamphetamine or cocaine users.

Who's behind the wheel? Driving with medically intractable epilepsy

OBJECTIVES

To examine driving in the context of people with medically intractable epilepsy, a population generally discouraged from driving.

METHODS

This study tested the relationship between a comprehensive set of factors and driving among 190 patients with a currently valid driver's license who were being evaluated for epilepsy surgery.

RESULTS

Almost one third (32.6%) of the sample reported currently driving. Distributional comparisons by current driving status revealed driving was significantly more prevalent among patients who were employed full-time and those who had not experienced a seizure-related MVA.

CONCLUSIONS

The decision not to drive in the context of a chronic medical condition is complex and influenced by a myriad of factors such as perceived illness susceptibility and severity.

Prevalence of abusive encounters in the workplace of family physicians: a minor, major, or severe problem?

OBJECTIVE

To examine the career prevalence of abusive encounters for family physicians in Canada.

DESIGN

A 7-page cross-sectional mailed survey in English and French.

SETTING

Canada.

PARTICIPANTS

A total of 3802 randomly selected practising family physicians who were members of the College of Family Physicians of Canada.

MAIN OUTCOME MEASURES

Demographic characteristics of survey participants, career prevalence of abusive encounters, and perpetrators of abuse.

MAIN FINDINGS

Twenty percent (20.4%) of the surveys (n = 774) were returned. Of the respondents, 44% were men and 56% were women. Most were in private practice in urban settings. The average number of years in practice was 15. The career prevalence of abusive encounters was divided into "minor," "major," and "severe" incidents. Of all the respondents, 98% had experienced at least 1 incident of minor abuse, 75% had experienced at least 1 incident of major abuse, and 39% had experienced at least 1 incident of severe abuse. Using chi(2) analysis, a number of demographic variables were found to be significantly associated with abuse including the physician's race and sex. Patients were the most common perpetrators of abuse. Ninety percent of family physicians surveyed reported that they had been abused by patients, while 70% reported that they had been abused by family members of patients.

CONCLUSION

Approximately 2 in 5 family physicians surveyed were subjected to a considerable amount of severe abuse during practice. Abuse in the office setting might have grave consequences for the health and well-being of the victimized physicians and might hinder service retention where the risk of abuse is greatest.